Procedures Pro ORTHOPEDICS

Peer Reviewed Laura E. Peycke, DVM, MS, Diplomate ACVS

Texas A&M University

Femoral Head & Neck Ostectomy

F
emoral head and neck ostectomy (FHO) is a commonly
performed procedure for surgical treatment of traumatic
and chronic conditions affecting the hip.

The option to do an FHO is typically presented along with

other surgical alternatives. Some surgeons see it as a last resort
or a salvage procedure, whereas others believe it to be a pri-
mary recommendation for many orthopedic diseases of the hip.

INDICATIONS
Common indications for an FHO include:
Femoral head and neck fractures
AUTHOR INSIGHT
Catastrophic acetabular fractures
Coxofemoral hip luxations
A thorough review and
Failed total hip replacements
understanding of the
Chronic pain associated with hip degenerative joint disease
craniolateral approach
(including traumatically induced disease, Legg-Perthes dis-
to the hip is recom-
ease, and canine hip dysplasia).
mended. Preservation
and reconstruction of
Excision of the femoral head and neck palliates pain by elimi-
the supportive soft tis-
nating bony contact between the pelvis and femur, allowing for-
sues are keys to a quick
mation of a pseudoarthosis. The pseudoarthrosis that forms
return to ambulation
comprises dense fibrous tissue lined by a synovial membrane.
and long-term function.
Recognition of the ori-
OUTCOME
gin and insertions of the
The procedure has the best outcome and is typically recom-
hip musculature is espe-
mended for mature pets and dogs weighing < 17 kg; however,
cially important if the
physically fit dogs of all sizes tend to rehabilitate and respond
FHO is performed on a
favorably regardless of their weight. In addition, muscle mass
hip that is luxated or
has been found to be one of the most important variables in
traumatized.
determining outcomes of the procedure.

Postsurgical FHO patients have some degree of limb shortening

and gait abnormality; however, with aggressive rehabilitation,
these animals have been reported to respond well to the proce-
dure and return to an active lifestyle.

FHO = femoral head and neck ostectomy CONTINUES

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STEP BY STEP FEMORAL HEAD & NECK OSTECTOMY

STEP 1
The animal should be routinely anesthetized using a premedication, an induc-
tion agent, and gas anesthesia; then placed in lateral recumbency with the
affected limb hung and aseptically prepared for surgery (A).

The hip is then draped routinely to

allow manipulation of the limb. A
proper craniolateral approach to the
hip is dependent on the identification
of the ischial tuberosity (white arrow),
the greater trochanter (arrowhead),
and iliac wing of the pelvis (red arrow)
(B).

A B

STEP 2
The skin incision should be made slightly cra-
nial to the greater trochanter in a proximal to
distal direction. The biceps femoris, tensor fas-
cia lata, and gluteal musculature should be iden-
tified and minimally disrupted until the
muscular planes are appreciated. The plane
between the tensor fascia lata and biceps
femoris are incised and separated. The tensor
fascia can then be retracted cranially, whereas
the biceps musculature is retracted caudally. The
superficial and middle gluteal muscles (arrow)
are identified and retracted dorsally without
excision of the musculature or tendinous inser-
tions. The deep gluteal muscle is identified by
the arrowhead.

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STEP 3
At this point, identification of the tendon of the deep gluteal
muscle (arrow) is possible (A). Gentle elevation (with a
periosteal elevator) of this tendon allows partial tenotomy and
identification of underlying hip joint capsule. The joint capsule
can then be identified and incised in a radial fashion along the
acetabulum and onto the femoral neck. Continuation of the A
incision along the origin of the vastus lateralis is recommended.
Elevation of the vastus lateralis musculature can be performed

B
and should be extended until full exposure of the femoral neck
is accomplished (B).

Because the
AUTHOR INSIGHT
hip has been STEP 4
draped out, movement of the hip and The head of the femur is freed
easier identification of the hip joint are from the remaining joint cap-
possible. Effective use of assistants and sule and round ligament with
additional Gelpi and Hohmann retrac- curved Mayo scissors or a Hatt
tors are important for visualization and spoon. Complete excision of the
adequate exposure of the femoral head round ligament is important to
and neck. When using pointed retrac- allow disarticulation of the hip
tors, care must be taken to avoid trauma and protection of deep struc-
to the sciatic nerve, which is located cau- tures when excising the femoral
dally in relation to the hip joint. head and neck.

STEP 5
Landmarks for the femoral head and neck are now visible AUTHOR INSIGHT
and include the medial aspect of the base of the greater
trochanter (arrow) and lesser trochanter (arrowhead), To position the saw or
located on the medial cortex of the femur. With adequate osteotome and perform ade-
quate excision of the femoral
A
elevation of the origin of the vastus lateralis muscle, direct
palpation of the lesser trochanter is possible and should neck, the limb must be main-
be performed. The lesser trochanter is best appreciated tained in external rotation so
as a small bump. that the knee is positioned at
90 degrees to the table while
The insertion of the iliopsoas muscle is also palpable at or the cut is being made. An
slightly distal to the lesser trochanter. Ideally, this muscular assistant can help the surgeon
insertion is preserved during the excision of the femoral neck, maintain the limb in the
but not at the expense of eliminating bony contact of the medial proper position.
femoral cortex with the pelvis.

Figure A shows the femoral head and neck prior to ostectomy;

Figure B shows how the femur should look when the correct B
cut is made during ostectomy.
CONTINUES

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STEP 6 STEP 7
Once the parameter for the femoral neck is appreci- Prior to the ostectomy,
ated, a line may be marked for accurate positioning Hohmann retractors
of an osteotome (at least 2- to 3-cm wide) or power can be placed on both
saw. The cutting device should be positioned on this the cranial and caudal
line and then tilted toward the patients head so that aspects of the femoral
the ostectomy is being directed in a caudal and neck. These retractors
medial direction. This ensures adequate bony tissue will help with tissue
will be removed on the most caudal and medial retraction and protect
aspect of the femur. the sciatic nerve and
underlying soft tissues.
The tendency to position the osteotome or saw in a With external rotation
perpendicular position in relation to the femoral of the limb being
neck will lead to incomplete excision of the femoral maintained, the cut is
neck and could result in residual contact between made.
the femur and pelvis. The orientation of the cutting
instrument should be tilted a few degrees toward
the dog's head.

STEP 8 Once the cut is completed, the tissue to be removed is grasped with a AUTHOR INSIGHT
bone-holding forcep. The femur is then carefully palpated for residual
bony prominences or irregularities. The hip is placed through a thor- When palpating the hip joint, free
ough range of motion. Any grinding or bony contact between the movement should exist through a
femur and hip should not be ignored. complete range of motion. Careful
debridement with rongeurs on the
At this point, the use of medial cortex can assist with elim-
rongeurs or a rasp can be used ination of bony contact.
to excise remaining tissue and
to smooth rough surfaces (A).
Inspection of the resected
femoral head and neck can give
some insight as to whether
additional tissue needs to be
excised (B).

A
B

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 AUTHOR INSIGHT
Orthogonal
STEP 9 view post-
operative radiographs should always
Once smooth range of motion has been acquired, closure of the hip may be be taken to ensure adequate excision
performed. Interpositioning of soft tissue between the femur and acetabulum of the femoral head and neck.
may be performed at this stage but remains controversial; proponents believe
this additional step increases the soft tissue padding between the ostectomy
site and pelvis. A positive outcome has been noted in short-term reports; how-
ever, there is no reported difference in long-term outcome.

In my experience, this technique not only requires additional soft tissue dissec-
tion and is unnecessary for long-term positive results but may also increase the
chances of deep tissue necrosis and infection.

STEP 10
Prior to closure, the surgical area
should be flushed with sterile saline.
Closure can be performed by closing
any residual joint capsule over the
acetabulum using 0 or 2-0 absorbable
suture. One or 2 mattress sutures can
then be placed in the deep gluteal
tendon to repair the previous teno-
tomy site. The vastus lateralis can
then be reattached to the deep tissues
by using simple interrupted sutures. See Aids & Resources,
All other superficial tissues are closed back page, for references
routinely. & suggested reading.

POSTOPERATIVE CARE Ice and heat therapies, along with ancies between the results of objective
The postoperative period is extremely antiinflammatory medications, can be clinical data and subjective observations
important to the recovery and return to used to assist with pain management. by owners, but a high degree of owner
function. It is critical to the success of Frequent rechecks to ensure mainte- satisfaction was reported following FHO.
the procedure to be clear about the reha- nance of hip range of motion should
bilitation plan with the client. be performed. PROGNOSIS
Rehabilitation in the form of passive If an FHO is performed properly (ade-
range of motion and controlled activ- COMPLICATIONS quate ostectomy and careful soft tissue
ity is encouraged and should be Complications associated with FHOs manipulation) and followed by aggressive
explored within the first days after include decreased range of motion (espe- rehabilitation, a positive outcome can be
surgery. cially abduction and extension of the expected; however, bony regrowth is
Swimming is also acceptable during hip), limb shortening, muscle atrophy, sometimes seen in dogs younger than 9
rehabilitation but should be postponed infection, and loss of function. A recent months of age.
until after the incision has healed. study reported that there may be discrep-

FHO = femoral head ostectomy

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